Quick GuideStroke Rehabilitation Certification

Checklist, key focus areas, and tips for preparing and applying for Joint Commission Stroke Rehabilitation Certification

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Document Checklist(Prepare prior to on-site review)

⃞ List of interdisciplinary team members with defined roles and responsibilities

⃞ Job description including, a list of roles and responsibilities for the program coordinator

⃞ Defined scope of the program including care, treatment, and services

⃞ Order sets, care paths, and protocols (if used by the program)

⃞ Clinical Practice Guidelines (CPGs)

⃞ Performance improvement plan

⃞ Patient education materials

⃞ Individual list of all inpatients being seen for stroke rehabilitation. Also have a list of the patients from the past four months seen for stroke rehabilitation

⃞ List should include the patient’s name, age, gender, diagnosis, and the location in your facility

⃞ A copy of the stroke rehabilitation program’s mission statement and scope of services

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Key Areas for Review

DEPARTMENTS

– Inpatient and outpatient services

– Care transitions

– Pharmacy

– Laboratory

– Physical therapy

– Referrals for palliative care/hospice, if needed

– Occupational therapy

– Human resources

STAFF

– Nursing staff

– Unit manager(s)

– Pharmacist(s)

– Lab technician(s)

– Physical therapist(s)

– Occupational therapist(s)

– Palliative care/hospice staff

– Medical staff

– Practitioners, including program team leader(s) and care coordinator(s)

– Educator(s)

– Human resources

– Case manager(s)

– Social worker(s)

– Data collection abstractor(s)

– Additional staff: leadership, human resources, regulatory, quality improvement staff, volunteers, and dietitian(s)

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Stroke rehabilitation Certification 1-Day Review

7:30 - 7 :45 AM

The reviewer will arrive and will routinely report to the main hospital entrance.

8:00 - 9 :00 AM

Opening Conference and Orientation to the program, and a brief review of the agenda

9:00 - 9 :30 AM

Reviewer(s) planning session (reviewer(s) will need this time to review your documents so please provide privacy)

9:30 - 12 :30 PM

Individual Tracers (open records and closed records as needed)

12:30 - 1 :00 PM

Lunch

1:00 - 2 :00 PM

Data Management Tracer

2:00 - 3 :00 PM

Competency Tracer, Credentialing and Privileging

3:00 - 4 :00 PM

Special Issue Resolution Session, as needed, and report preparation

4:00 - 4 :30 PM

Closing Conference

4:30 PM

The reviewer(s) will exit your organization

Note: All times are approximate and may be changed when the hospital staff discusses with the reviewer(s)

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Opening Conference

– Ensure attendance of representatives from all areas that support the program including: leadership, all departments that are part of the Stroke Rehabilitation program for the patient and physician(s)

– Orientation to the program and the opening conference will be a total of 60-minutes. Please plan to provide a presentation about your program. A common practice is to prepare a PowerPoint presentation outlining important aspects of the program. In your presentation to the reviewer(s), focus on providing an overview of your stroke rehabilitation program. Please keep your presentation to 15-20 minutes. Areas to consider include:

– Mission statement

– Target population (including unusual populations)

– Volumes of patients in the stroke rehabilitation program

– Identify interdisciplinary team members

– Reporting structure for stroke rehabilitation program leader(s)

– Model of care

– Dashboard metric overview for key areas (remember you have a full data session later in the day to share all data)

– Services available to patients in the stroke rehabilitation program

– Method in which you provide performance improvement data to leadership, and other staff members

– Multi-disciplinary team planning (rounds, team planning meetings, etc.)

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Individual Tracers

The majority of on-site review time is spent in tracer activity. Here are some tips to make these go smoothly:

– Designate an area out of the public space for the reviewer(s) to interview staff (conference room, classroom or break room, etc.)

– Introduce the reviewer(s) to the director/manager, and charge RN on the unit so they know they are present

– RN should be ready to start the tracer when the reviewer(s) arrives. If you use an EMR, a staff member familiar with navigating the EMR should accompany the team

– All staff on the unit should be able to speak to their stroke rehabilitation orientation and on-going stroke rehabilitation education

– As available, additional staff should join the group: care coordinator(s), occupational therapist(s), physical therapist(s), physician(s), APN(s), dietitian(s), social worker(s), case manager(s), lab staff, and others

– Staff should be prepared to speak to their formal processes for care and multi-disciplinary care practices

– Assessments and re-assessments will be a focus

– Patient procedures and handoff communication are reviewed

– All staff should be able to speak to performance improvement processes

– Individualized patient goal setting should be reflected in the EMR. There should be evidence as necessary of discussions regarding behavior modification for risk factors

– Behavior modification for risk factors

– Patient and caregiver education

– Assessing the patient’s ability and willingness to learn

– Preparing the patient and caregiver for discharge

– Follow-up care coordination

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System Tracer – Data Management

– Many organizations use a PowerPoint presentation to share their PI data as it relates to their stroke rehabilitation program. This is one of the best methods for The Joint Commission to view your data, as it allows for all team members to see and discuss the same data points at the same time

– Ensure reports have date range and “N” noted with volumes

– Tracer will start with a discussion of how you utilize the data you collect in your hospital to improve your program

– Prepare to speak to how you collect, analyze, and share data to make improvements in your program on a continuous basis

– Attendees from across the hospital who are involved in the collection or interpretation of the data should attend the session

– Include your patient satisfaction data in this session as it relates to the program

– Present data on selected performance measures

– Share all data collected for your program (this should indicate how committed you are in improving different aspects of your program)

– Prepare questions for the reviewer(s) on how to improve your data collection methods, changing your measures, areas to focus on, etc. (ask about best practices seen in other stroke rehabilitation programs)

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System Tracer – Credentialing and Privileging Discussion

Reviewer(s) will want to discuss the following:

– MD and APN license

– Current DEA

– Appointment and re-appointment to the medical staff

– OPPE and FPPE

– Credentialing and privileging documents for all LIPs

System Tracer – Competency

Discussions and review in this session will revolve around staff encountered or identified through patient tracer activity, including:

– Staff identified through tracers (open and closed records) RN, care coordinator(s), case worker(s), social worker(s), pharmacist(s), OT, PT, and others

– Reviewer(s) will want to see the following information regarding the staff:

– License/certificate per job description

– Current job description

– Copies of all education records related to stroke rehabilitation per organization hour/ course requirement

– The reviewer(s) will review education on a rolling annual basis

– Copies of certificates (BLS, ACLS, etc.) and degrees per job description

– Orientation checklist

– Most recent performance evaluation

– Education for staff who work in specialty areas (ICU, CCU, procedural areas) should include documentation of education

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Closing Conference

– The organization can select who they want to attend the closing conference

– You will be able to print the preliminary report once the reviewer(s) makes it available on your extranet just prior to the closing conference

– The reviewer(s) will discuss the results of the on-site evaluation

– The reviewer(s) will share if they identified any best practices while at your organization and indicate how you can submit them to The Joint Commission’s Leading Practice Library

Tips for Customers

– The Joint Commission will provide a 30-day notice for initial certification customers and a seven day notice for recertification customers

– Ensure your Certification Measure Information Process (CMIP) data is up to date

– Ensure your CPG’s are reviewed annually

– Ensure your organization’s website is up to date with staff, services, certification for stroke rehabilitation, etc.

– During the planning session, the reviewer(s) will identify which patients will be traced during the patient tracers. Notify your staff on the inpatient units which patients will be traced so they can prepare for their day

– Closed records should be ready for review during the late morning (approximately 11:00 a.m., depending on the number of closed records that need to be reviewed). The reviewer(s) will need at least two computers on wheels (charged) and staff who are able to easily access and maneuver through closed records

– In order to ensure an efficient review process, we may ask two staff members to find different information on the same patient at the same time

– Ensure your team is ready to accompany the reviewer(s) during tracers at the beginning of the day and after lunch

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– Please consider limiting the number of staff who accompany the group. This is for your clinical staff’s comfort

– Suggested staff you may want to consider to accompany the reviewer(s):

– Stroke rehabilitation team member

– If you use an EMR, a staff member familiar with navigating the EMR should accompany the team

– Make sure you have a secured locked area for the reviewer’s personal items

– The reviewer(s) will eat their lunch alone. This provides an opportunity for the customer and the reviewer(s) to have downtime. The reviewer(s) will also take this time to assimilate their thoughts, review documents, call the Central Office Standards Interpretation Group (SIG) if needed, or check on other items needed for your review

– Patient satisfaction data for the stroke rehabilitation program will be reviewed. This is specific to the program, not to the hospital

– Be timely when the reviewer(s) requests to see a policy, guideline, CPG, order set, MD order, procedure note, or other documents. All documents given to the reviewer(s) after the report is locked and published to The Joint Commission will need to be submitted during the 10-day clarification period

– The reviewer(s) will start their report and notify you when it is published at the end of the day

– Once the report is locked, the reviewer cannot unlock the report

– You can find the report under your Joint Commission extranet site where you found the information for your on-site review

– You can print the preliminary report for your leadership staff. Remember, the preliminary final report may be changed after an internal Joint Commission review by the Standards Interpretation Group (SIG) at The Joint Commission

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– If you do not agree with a Requirement for Improvement (RFI), simply let the reviewer(s) know. You can discuss the findings during the Special Issue Resolution session. If the reviewer(s) decides not to change the RFI, they have the ability to “flag” the finding(s). The Standards Interpretation Group (SIG) will review it and get back to you with their decision on the finding(s). They may request additional documentation in order to review the finding(s). Please submit the additional documents directly to the Standards Interpretation Group (SIG)

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Value for You, Our Customer

WORK WITH A PREMIER CERT IFY ING BODY

– The Joint Commission is the nation’s oldest and the largest certifying body setting standards for safe, high-quality health care for health care nationally, and internationally

– We accredit and certify nearly 21,000 health care organizations and programs in the United States

GET VALUE -BASED CERTIF ICAT ION

– Evidence-based standards

– Solid/broad clinical and professional expertise for development and maintenance of standards

– Technical Advisory Panel of national experts from across the country is involved in standards development on a continuous basis

COLLABORATE WITH EXPERT REVIEWER(S)

– Our reviewer(s) are subject matter experts in stroke rehabilitation who utilize current, contemporary and relevant knowledge when reviewing your program

– Reviewer(s) make the review process as transparent as possible and collaborate with you and your team throughout the on-site event to avoid any surprises at the end of the review

– We are committed to ensuring that subject matter experts review your program. Our reviewers currently work in the area of stroke rehabilitation in a health care organization. This ensures that they are current, contemporary, and relevant when reviewing your program

– Our reviewers consist of advanced practice nurses and physical/occupational therapists

– Reviewer(s) will make the review process as transparent as possible

– No surprises at the end of the review. If we identify an issue, we will point it out to you immediately and provide an opportunity for you to address the situation

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– We acknowledge staff for their contributions to the process and the program

– Collaboration, engagement, and sharing of best practices allows you to continually improve your program and ensure it is prepared to meet the needs of a continually changing health care environment. If we identify leading practices, we will present this information to your team at the closing conference

– Improvements in our programs are made based on customer feedback. Please consider the opportunity to complete the Customer Value Assessment and the reviewer(s) evaluation. The Joint Commission is committed to you as our customer. We review all feedback and, as appropriate, share it with the reviewer(s). Your feedback allows us the opportunity to ensure that we are being consistent among the team of reviewer(s) when we review your program

CERTIF ICAT ION

– Provides a framework to improve patient outcomes

– Helps to organize teams across the continuum of care

– Provides a competitive edge in the marketplace

– Enhances the facilities ability to attract top level talent

Achieve Certification that Sets Your Program Above the Rest

– Designates excellence in stroke rehabilitation certification

– Assists organizations to establish a consistent approach to care and reduce the risk of error

– Demonstrates commitment to a higher standard of clinical service

of our customers have reported improved patient outcomes as a result of certification through The Joint Commission.*

* Value of Certification, Market Research, 2016

92%

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Notes

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Notes

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Thank you for choosing The Joint Commission for all of your program certification needs. We appreciate the opportunity to work with you to provide high-quality care to your patients.

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CONTACT US

Receive complimentary resources/tips and an overview of the application process. (630) 792-5291 certification@jointcommission.org